Hallux Valgus – 6 Interesting Facts, Symptoms, Causes, Diagnosis and Treatment

6 Interesting Facts of Hallux Valgus

1. Hallux valgus is a common progressive forefoot deformity consisting of lateral deviation of the hallux (big toe) at the metatarsophalangeal joint accompanied by medial deviation of the first metatarsal (metatarsus primus varus)
   • Great toe angulates away from midline and toward other toes
   • Bony eminence at medial aspect of first metatarsal head is referred to as a bunion
2. Heredity and constricting footwear are considered major contributing factors
3. Deformity may be asymptomatic or result in foot pain and dysfunction
   • Pain typically located over bunion or beneath the lesser metatarsophalangeal joints
4. Diagnosis is based on clinical history, physical examination, and radiographs
   • Radiographs assist in deformity assessment and treatment planning
5. Treatment consists of conservative and surgical measures
   • Conservative treatment is the preferable first option and may improve symptoms and function, but it does not correct the deformity
   • Many surgical procedure options are available; success depends on choosing best technique for a given deformity
6. After appropriate surgical intervention, most patients are satisfied and have good clinical result

• Hallux valgus is a common progressive forefoot deformity consisting of lateral deviation of the hallux (big toe) at the metatarsophalangeal joint accompanied by medial deviation of the first metatarsal (metatarsus primus varus)
  • Great toe angulates away from midline toward other toes
• With progression, the first metatarsal head slides medially off the sesamoids
  • Bony eminence at the medial aspect of the first metatarsal head is referred to as a bunion
    • Thickening or inflammation of the bursa overlying the first metatarsal head can accentuate this medial eminence

Clinical Presentation

History

• Clinical history of Hallux Valgus includes duration of symptoms, activity modification, usual footwear choices, previous interventions, history of foot trauma or arch collapse, and familial inheritance
• Pain may be present
  • Patients may complain of great toe “pointing inward” (ie, laterally) toward other toes and causing:
    • Difficulty fitting desired footwear owing to deformity
    • Cosmetic concerns
  • Symptoms can include:
    • Pain
      • First metatarsophalangeal joint pain, soreness, or stiffness
        • Inflammation of overlying bursa can cause pain over medial eminence
      • Pain may be located beneath the lesser metatarsophalangeal joints
        • Malfunction of a given metatarsophalangeal joint may produce pain at another metatarsophalangeal joint
      • Pain/pressure under second or third metatarsals can result from transfer metatarsalgia (pain at different ray than mechanically impaired ray)
      • Typically worse when wearing tight shoes or high heels and with weight bearing
    • Burning or numbness owing to compression of digital nerve

Physical examination

• Both bare feet examined in sitting and standing positions
  • Observation
    • Gait may be antalgic or externally rotated
    • Alignment
      • Medial deviation of first metatarsal and lateral deviation of hallux
      • Pronation of hallux (nail faces medially)
    • Inflammation and edema over medial eminence; ulceration may be noted
    • Forefoot may be wide
    • Deformities of lesser toes, midfoot, or hindfoot
      • Pressure of the great toe against the second toe may lead to malalignment, subluxation, or dislocation of the second metatarsophalangeal joint
    • Thickened skin over metatarsophalangeal joint and/or plantar surface (callus)
• Palpation
  • Focal tenderness to palpation over medial eminence
    • Tenderness over dorsal hallux metatarsophalangeal joint may indicate arthritic component
  • Tender plantar calluses indicate transfer lesions under the lesser metatarsophalangeal joints
    • Owing to shift in load-bearing capacity from first ray (metatarsal, sesamoids, and hallux) across to lesser toes
• Range of motion
  • Decreased mobility of metatarsophalangeal joint
    • Active and passive range of motion is assessed
      • With neutral position as recorded 0°, average passive dorsiflexion is 67°, and plantar flexion is 20° in adults aged over 45 years 
    • Motion evaluated in reduced and nonreduced positions
      • Manual attempt to reduce deformity is made while gently dorsiflexing and plantar flexing the first metatarsophalangeal joint; can determine degree of correction that may be achieved 
        • If motion is increased in reduced position, it may suggest contracture of lateral soft tissues
        • If motion is decreased in reduced position, it may indicate a change in the articular surface angle
        • If motion is restricted in reduced or nonreduced position, there may be degenerative change
      • Pain or crepitus may indicate degenerative changes
    • Toe pronation on extension can indicate intrinsic malalignment
  • Hypermobility of first ray
    • Increased laxity of the first metatarsocuneiform joint may contribute to deformity 
      • Examination performed with ankle in neutral dorsiflexion
      • Second metatarsal head is stabilized with 1 hand while first metatarsal head is moved dorsomedially then plantar-laterally to gauge degree of hypermobility; compared with contralateral side
        • Grading may be described as mild, moderate, substantial mobility, and hypermobile 
        • Technique has consistent intrarater reliability, but little clinical objectivity comparing magnitudes among examiners 
    • The second metatarsophalangeal joint should also be examined
  • Ankle, subtalar, and transverse tarsal joints
    • Hindfoot deformity may contribute to development of forefoot issues
      • Ankle joint: assessed by dorsiflexing and plantar flexing the foot at level of ankle joint
        • Allows sagittal plane motion of 20° of dorsiflexion to 50° of plantar flexion along an axis running between tips of the malleoli; marked variability between individuals 
      • Subtalar joint: assessed by holding heel with palm of 1 hand, fingers on posterior heel; with other hand, the foot is inverted and everted
        • Range of motion approximately 30° of inversion and 15° of eversion; magnitude variable between persons 
      • Transverse tarsal joint: evaluated by holding heel with palm of 1 hand, fingers on posterior heel; with other hand, the foot is abducted and adducted
        • Normal motion is approximately 20° of adduction and 10° of abduction 
• Peripheral vascular perfusion and motor/sensory function are evaluated
  • Vascular occlusive disease can preclude surgical options
  • Numbness or paresthesia over the dorsomedial distal phalanx can result from compression/irritation to dorsal cutaneous nerve overlying the bursa 

Causes

• Cause of hallux valgus is uncertain but likely multifactorial, including: 
  • Intrinsic factors
    • Genetic variations that result in altered biomechanics
    • Sex (more common in females than in males)
    • Ligamentous laxity
    • Other foot deformities (eg, pes planus, pronated hindfoot, metatarsus primus varus)
    • Age (prevalence increases with age)
    • Neuromuscular disorders (eg, cerebral palsy, stroke)
  • Extrinsic factors
    • Footwear (high heels, narrow toe box)
      • High heels increase forefoot loading; may exacerbate deformity 
    • Excess weight bearing
• Progressive deformity involves several steps, in concert with predisposing factors; often a parallel process rather than sequential 
  • Begins with lateral deviation of great toe and medial deviation of first metatarsal
  • Later stages involve progressive subluxation of the first metatarsophalangeal joint
  • Bursa over joint thickens over time owing to pressure of footwear on medial eminence 

What increases the risk of Hallux Valgus?

Age

• Prevalence increases with age
  • Age of onset varies widely

Sex

• Affects women more commonly than men
  • May be associated with more narrow, high-heeled footwear

Genetics

• Familial association
  • 83% of patients have a positive family history of hallux valgus deformities

Other risk factors/associations

• Tends to be bilateral
• Other possible associations include:
  • Long first metatarsal
  • Oval or curved metatarsophalangeal joint articular surface
  • Increased first ray mobility
  • Achilles tendon tightness
  • Pes planus
  • Plantar gapping of first metatarsal cuneiform joint

How is Hallux Valgus diagnosed?

Primary diagnostic tools

• Diagnosis is by clinical history, physical examination, and radiography 
• Obtain dorsoplantar and lateral weight-bearing radiographs for all patients with suspected hallux valgus 
• Additional radiographic views may be necessary to assess deformity and assist in treatment planning, but advanced imaging is typically not necessary

Imaging

• Weight-bearing dorsoplantar and lateral radiographs of the feet
  • 2 important angles are assessed to determine radiologic severity
    • Hallux valgus angle
      • Angle between long axes of proximal phalanx and first metatarsal
    • Intermetatarsal angle: 
      • Angle between long axes of first and second metatarsals
  • Other angles that may be useful in treatment planning include:
    • Distal metatarsal articular angle (10°-15°) 
    • Hallux interphalangeus angle (normal angle less than 10°) 
• Severity of hallux valgus can be classified based on standing anteroposterior radiographs 
  • Normal
    • Hallux valgus angle: less than 15°
    • Intermetatarsal angle: less than 9°
    • Subluxation of lateral sesamoid on anteroposterior view: none
  • Mild
    • Hallux valgus angle: less than 20°
    • Intermetatarsal angle: 11° or less
    • Lateral sesamoid subluxation: less than 50%
  • Moderate
    • Hallux valgus angle: 20° to 40°
    • Intermetatarsal angle: less than 16°
    • Lateral sesamoid subluxation: 50% to 75%
  • Severe
    • Hallux valgus angle: greater than 40°
    • Intermetatarsal angle: 16° or greater
    • Lateral sesamoid subluxation: greater than 75%
• Other radiographic observations that can be useful in guiding treatment include: 
  • Various other angular and positional relationships (eg, distal metatarsal articular angle, interphalangeus angle)
  • Metatarsal head shape
    • More convex articular surface is more prone to hallux valgus deformity
  • Position of sesamoids relative to metatarsal head
    • May demonstrate severity of deformity, degree of pronation, and pathologic changes in sesamoids
  • Gapping of plantar aspect of first metatarsocuneiform joint
  • Arthrosis of metatarsophalangeal joint
  • Metatarsus adductus
  • Presence of intermetatarsal facet or os intermetatarseum
• Additional radiographs can include nonstanding lateral oblique views and axial sesamoid views 
  • Axial sesamoid view may aid in determining extent of intrinsic malalignment
  • Can be useful preoperatively

Differential Diagnosis

Most common

• Hallux rigidus
  • Osteoarthritis of the first metatarsophalangeal joint
  • As with hallux valgus, symptoms include pain, stiffness, and swelling at first metatarsophalangeal joint
  • Differentiated by tender bump (bunion); if present, typically located on dorsal aspect of metatarsophalangeal joint
    • Examination may show limited and painful range of motion, especially dorsiflexion; crepitus may be noted
  • Diagnosis based on physical examination and radiographs (eg, sclerosis, subchondral cysts, joint space narrowing, osteophytes, dorsal bone spur)
• Gout
  • Gout is a common inflammatory arthritis caused by deposition of monosodium urate crystals
  • As with hallux valgus, symptoms include pain, stiffness, and swelling at first metatarsophalangeal joint
  • Differentiated by relatively acute onset of pain, redness, and swelling in joint
  • Diagnosis based on history, physical examination, and laboratory testing
    • Definitive diagnosis by joint aspiration
      • Diagnostic gold standard for gout is presence of negatively birefringent monosodium urate crystals in a synovial fluid sample viewed under polarized light microscopy 
    • Important to differentiate from septic joint
• Rheumatoid arthritis (Related: Rheumatoid Arthritis)
  • An autoimmune disease; immune complexes within synovial membrane cause inflammatory response leading to synovial thickening and joint destruction
    • Frequently affects joints of the feet; hallux valgus is predominant foot deformity 
  • Similar symptoms include pain, swelling, and stiffness; resulting deformities include bunions, claw toes, and metatarsalgia
  • Affects multiple joints; typically both feet and similar joints involved (symmetrical)
  • Diagnosis based on clinical criteria, laboratory results (eg, levels of rheumatoid factor, anticyclic citrullinated peptide; antinuclear antibody assays), and imaging features (eg, erosions, joint space narrowing)
• Septic arthritis
  • Infection within joint space; typically bacterial
    • Important to consider in patients with acute joint disease
    • Can lead to rapid, irreversible joint destruction; associated with significant morbidity and potentially fatal
  • Similarly, presents with joint pain, redness, and swelling
  • Differentiated by relatively acute symptom onset; fever may be present
  • Diagnosis suggested by clinical history, physical examination, and laboratory testing (eg, WBC count, erythrocyte sedimentation rate, C-reactive protein levels)
    • Joint aspiration with synovial fluid analysis and culture is essential for the diagnosis 

Treatment Goals

• Relieve pain
• Prevent progression
• Accommodate existing deformity
• Improve function
• Restore articular anatomy (requires surgical correction)

Disposition

Recommendations for specialist referral

• Refer to specialist (eg, orthopedist, podiatrist) for possible surgical intervention when conservative measures fail 

Treatment Options

Treatment consists of conservative (nonsurgical) and surgical measures

Conservative treatment

• Preferable as first option
  • Primary therapy in juvenile hallux valgus, elderly patients, and those with severe neuropathy, vascular compromise, or other comorbidity in whom surgery is contraindicated 
• Does not correct the deformity but may improve symptoms and function 
• Modalities include: 
  • Analgesics (eg, NSAIDs)
  • Footwear choice: wide toe box, soft shoe with sufficiently padded insole, avoidance of high heels
  • Physical therapy
    • May be useful alone for mild hallux valgus, or in addition to other conservative treatments
    • Can include gait training, exercise, manual therapy, taping, and orthosis
  • Activity modification
  • Orthotics (shoe inserts)
    • May provide symptomatic relief in some patients
    • Can include medial posting (to control pronation), metatarsal pad/bar (for transfer lesions), bunion flare, and extra-deep shoe with oblique toe box (accommodative) 
    • A Cochrane review found orthoses reduced foot pain after 6 months (compared with no treatment) but did not reduce foot pain after 6 or 12 months compared with surgery in patients younger than 60 years 
  • Toe spacers
    • Wearing insole with toe separator may decrease pain intensity; not effective in improving great toe angles

Surgical

• Symptomatic patients in whom conservative therapy fails are candidates for surgical correction 
  • Continued pain and dysfunction (disruption of lifestyle/activities) are indications for surgical consideration
  • Not recommended for cosmetic repair in asymptomatic patients owing to inherent surgical risks 
  • Principal contraindication is arterial occlusive disease; indistinct pedal pulses must be evaluated further 
• Over 150 techniques have been described
  • Diversity of surgeries partially owing to the multiple factors causing hallux valgus 
  • A Cochrane review concluded no technique has been shown to be superior 
  • Must be individualized for each patient
• Surgical success depends on choosing best procedure for individual given deformity 
  • Guided by careful evaluation of conventional radiographs
    • Various factors considered, including hallux valgus angle, intermetatarsal angle, distal metatarsophalangeal joint congruity, and presence of arthritis 
  • Surgeon’s expertise and experience are factors 
  • Management of patient expectations is important; ability to wear desired footwear or perform high-impact activity should be tempered 
    • Up to 41% of patients are not able to return to desired footwear choices 
  • Options include various procedure categories, alone or in combination: 
    • Distal soft-tissue reconstruction
    • First metatarsal osteotomies (distal and/or proximal)
    • Proximal phalanx osteotomies
    • Arthrodesis (fusion)
    • Excisional arthroplasty
• Postoperative physical therapy and gait training may aid in improving function after surgery 

Nondrug and supportive care

• Patient education
  • Inform patients about progressive nature of disease process as well as treatment options and realistic goals

Special populations

• Juvenile (pediatric) hallux valgus
  • Relatively uncommon in children
  • Usually asymptomatic in pediatric population; typically comes to medical attention owing to cosmetic appearance of bunion
  • Radiographs, in addition to showing underlying deformity, provide assessment of epiphyseal plates to aid in management decisions
  • Treatment is typically conservative until after skeletal maturity
    • Surgical correction associated with high recurrence rate and variable clinical outcomes; higher risk of overcorrection
      • Delay is preferred until skeletal maturity unless significant pain and deformity interfere with daily living
      • Epiphyseal injury may result in growth disturbance

Complications

• Complications of hallux valgus include:
  • Osteoarthritis of first metatarsophalangeal joint
  • Deformation and pain in other digits forced upward resulting in hammer or claw toes 
  • Lateral metatarsalgia owing to pressure transfer from great toe to lateral metatarsal region 
• Surgical complications include: 
  • Recurrence (foremost complication)
  • Nonunion
  • Avascular necrosis
  • Hallux varus
  • Transfer metatarsalgia
  • Neuromas
  • Hyperesthesia
  • Degenerative arthritis
  • Unmet patient expectations

Prognosis

• Left untreated, condition has uncertain prognosis
  • Deformity and symptom progression may be rapid in some people whereas others remain asymptomatic
• After appropriate surgical intervention, 85% of patients are satisfied and have good clinical result 
  • 10% are less satisfied, with suboptimal outcome; 5% have poor results 
  • Relief of pain is primary objective, but ability to wear smaller/narrower shoes is a frequent goal
    • Up to 41% of patients are unable to return to desired shoe choices 

Prevention

• No prevention strategy known; cause is likely multifactorial, involving interplay between intrinsic and extrinsic factors

References

Coughlin MJ et al: Hallux valgus: demographics, etiology, and radiographic assessment. Foot Ankle Int. 28(7):759-77, 2007 Cross Reference